Value PPO Plan

With this option, you have the flexibility to see providers who meet yours or your family’s health care needs. “PPO” refers to “preferred provider organization” – an important feature of this type of medical plan.

Here’s how it works:

The Value PPO option has two level of benefits: Network and Non-network. Each time you need care you decide whether to see a network or non-network provider. You receive higher benefits when you see network providers. Network providers will also file claims for you. To see a list of network providers for your area, sign on to www.myuhc.com.   

Deductible applies to all network and non-network services except where noted. 
Summary of Benefits Network Provider Non-Network Provider

Physician Services

    Primary Care Physicians

    Specialists 

 

$20 Co-payment

$30 Co-payment

(Deductible does not apply)

 

50% of MNRP*

Preventive Care

$20 or $30 co-payment up to $300/person

(Deductible does not apply)

Not-covered

Well Baby Care

$20 co-payment/office visit up to 2nd birthday

(Deductible does not apply)

Not-covered

Hospital Inpatient

80%

50% of MNRP*

Hospital Outpatient

80%

50% of MNRP*

Emergency Room

80% after $75 co-pay for emergencies (deductible does not apply)
 (co-payment is not waived even if admitted)

80% after $125 co-pay for non-emergencies (deductible applies)

(co-payment is not waived even if admitted)

80% of MNRP* after $75 co-pay for emergencies (deductible does not apply)

(co-payment is not waived even if admitted)


50% of MNRP* after $125 co-pay for non-emergencies (deductible applies)

(co-payment is not waived even if admitted)

Urgent Care Centers

$30 Co-payment

(Deductible does not apply)

50% MNRP*

Surgery

80%

50% MNRP*

X-ray & laboratory

80%

50% MNRP*

Prescription Drugs

(one month supply)

Tier 1:  90% ($10 min/$20/max)

Tier 2:  80% ($25 min/$45 max)

Tier 3:  60% ($50 min/ $70 max)

(Deductible does not apply) 

Not covered

Mail Order Prescription

(3 month Supply)

Tier 1:  90% ($20 min/$40/max)

Tier 2:  80% ($50 min/$90 max)

Tier 3:  60% ($100min/$140 max)

(Deductible does not apply) 

Not covered

Mental Health & Chemical Dependency

Inpatient 80%

Outpatient 80% after a $20

co-payment

Inpatient 50%

Outpatient 50%

Deductible **

$600/person $1,200/family

$1,000/person $2,000/family

Co-insurance maximum

$2,500/person

$5,000/ family

$5,000/person

$10,000/ family

Life time maximum

none

* Maximum Non-Network Reimbursement Program (MNRP) as determined by United HealthCare

 ** Deductible applies to all network and non-network services except where noted. 

Employee Bi-Weekly Cost (Effective January 1, 2011)

Employee Only

$67.06/bi-weekly

Employee & Child(ren)

$116.62/bi-weekly

Employee & Spouse

$141.09/bi-weekly

Employee, Spouse & Child(ren)

$209.16/bi-weekly

 

Primary Care Physicians includes Family Practice, General Practice, Internal Medicine, Pediatricians, and OBGYNs.

 

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Revised: January 03, 2011.